Nursing in Africa

In large parts of Africa, decades of war, conflict and instability have left its people with limited access to basic healthcare services. This is aggravated by the fact that the continent carries 25% of the global disease burden and the lowest number of global healthcare worker per capita.
The challenges that impact healthcare service delivery in Africa include (but are obviously not limited to) lacking infrastructure, poor management, lacking equipment, variable care standards and supply chain issues. In 2001, in an attempt to address some of these challenges, the countries belonging to the African Union (AU) committed to allocate 15% of their fiscal budget to healthcare (Abuja declaration 2001). Sadly only six countries succeeded in doing that. It is estimated that even if all of the AU countries allocated 15%, the size of their budgets are simply not enough to address and overcome some of the challenges that face healthcare systems in Africa.
The budget size and lack of allocation or investment in healthcare leads to another problem: dependency on donor funding. Unfortunately donor funding comes with vested interests and may inadvertently contribute to the vertical development of disease specific fields at the expense of horizontal or strengthening of the whole health system. A good example of this is HIV research that across the continent is disproportionately represented and funded.
Because the burden of disease and the demand for healthcare services that’s continuously rising, larger budgets and more healthcare workers are required. Alarmingly statistics demonstrates that in some African countries there has been a decline in the number of healthcare workers over the past twenty years. In addition, there is a known distribution of healthcare workers towards urban areas, leaving rural areas without adequate healthcare delivery structures and staffing.
In most of Africa, the first healthcare worker to provide care to a patient is a nurse (WHO2008). With nurses being the mostly widely spread and available health professionals on the continent, their role cannot be overestimated. Creating more enabling environments for nurses to be educated and work in better conditions should be prioritized. A few issues that seem to be universal to the ability of nurses to perform in Africa are highlighted below. These issues draw on my experience and my conversations with local nurses in the settings in which I’ve worked.
Quality and appropriateness of nurse training
Formal nursing education was brought to Africa by imperialism. This implies that the people who brought formal nursing education to Africa introduced it in a similar way to how it was done in the countries that they came from. Most of these models were (and still are) based on training nurses in-hospital and where one of the primary roles of the nurse is as team member with a medical doctor and others. This is very different from community based care that’s prevalent and required in rural Africa. In most of Africa, the nurse is often a solo practitioner that’s far from hospitals and other team members. The training of the nurses should prepare them for such roles and situations.
Clinical and educational gaps can be identified by furthering research, especially nursing science research in Africa. This then allows the design of curriculum’s that are contextually relevant to the needs of the continent. This is, however, complicated by other issues, namely:

Limited research on indigenous diseases in Africa
Most of the infectious diseases that are endemic to Africa such as schistosomiasis or trypanosomiasis are not well-researched. With limited evidence based guidance, there can be no best nursing practice for these endemic diseases.
The fields that are researched are according to donor specialization and interest. Sun and Larson (2015) did a review of all nursing research from Africa that was published over a decade and found that the most studied areas were associated with funding resources. They also found that prevalent conditions in Africa e.g. malnutrition, diarrhoea disease and other common causes of death were not studied and/or published. This demonstrated a clear gap between the healthcare needs and the fields researched.
Nursing research needs to focus and address the glaring healthcare issues in Africa. Often care in villages is rendered by persons with no training in healthcare, and addressing issues like the need for reliable community based care when developing curriculums or conducting research could impact the health systems tremendously.

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Training facilities
Training facilities across Africa lack enough classrooms, electricity, running tap water and technological advances. Internet has been reported as a scarce resource across various training settings in Africa. The access to electronic resources is limiting for both students and educators. Open-access resources have helped to make science more accessible globally, but there is still a high cost to obtaining research and information making it incredibly tough to stay abreast of new guidelines, especially for nurses in Africa.
Clinical guidance in hospitals is lacking and there are limited simulation models at training facilities. At some of the facilities where I’ve conducted training there have been no CPR manikin’s or other additional models for training. In most places we had to innovate and make our own manikins and other adjuncts.
For healthcare workers in rural areas, obtaining further education or refresher training means uprooting and even leaving a healthcare facility unattended for the duration of their training. This should be considered when we think about educating and upskilling nurses.
Knock-on impact of the doctor shortage in Africa
The lack of doctors, especially in rural areas has resulted in task shifting. Task shifting occurs when tasks that would normally be seen as the doctors’ domain, are shifted to nurses. It increases the nurses’ workload and the nurses are expected to perform tasks that they have not received training for.
The distribution of health facilities and different tiers of care means that the large drainage areas in the rural districts are often manned by nurses without any further medical support close by. This means that the nurses working in rural areas are isolated when dealing with cases that are not within their scope of practice, limited clinical guidelines and difficulty in obtaining help. Telemedicine and technology may offer some solutions provided that it can be reliable in areas with limited electricity, currently no internet etc.

Regulatory issues
In many African countries, graduates are not subject to registration with a statutory body. There may be professional associations, but there is no compulsory registration process and professional licensing. In countries with no regulatory body, there is no representation to lobby for nursing rights or amendments to Acts of Parliament, salaries for nurses or to promote career progression.
Often healthcare worker salaries (including doctors) are not paid on time, if at all. This leads to some healthcare workers having secondary streams of income or funding their own incomes out of privately charging patients’ higher fees.
Gender inequality
In most African societies, gender equality has not yet been achieved. Women receive less education than men, they have less rights and their voice are not heard in the same way. Nursing remains a predominantly female profession and this limits the ability of nurses to assert themselves and it impacts on the ability of the profession to influence national policy.
There is a trend where even though the nurse workforce is mainly female at service delivery level, at top management and policy level it’s represented by men. In the DRC it was established that only 1% of the nurses are male, yet more than 90% of the top levels and education facilities positions are filled by men.
The social determinants allowing people to access healthcare includes basic primary education and gender equity amongst other factors. Sadly neither one of these has been achieved for nurses in Africa and it hampers the progress of nursing education and research across the continent.
Career progression
This tie in with the above, and the fact that because of the role of women in society, nurses being mostly female and the difficulties faced by nurses to render care, career progression may be stunted. Because healthcare workers in rural areas need to travel to further education and because nurses are predominantly women, it is hard for them to leave home and obligations at home to further their career.
Lack of mentorship and language barriers
There is a lack of mentorship to help nurses further themselves as researchers and educators. Organizations such as the AFEM Nurses Group developed a mentorship program with international mentorship support to African nurses. Another program is the Nursing Education Partnership Initiative (NEPI) that was formed in 2011 by PEPFAR to improve nursing and midwifery education in Africa. We need more programs like this.
Mentorship, inclusion into global healthcare networks, research and education are complicated by language barriers. Often nurses working in rural areas do not read or speak English; the language which much of the training material and research is presented in.
Conflict
It has been postulated that there’s a statistically significant relationship between accessibility to care and civil conflict (Rhode 2015). Unrest and conflict creates havoc on the ability to deliver healthcare, train providers, obtain supplies and in violent prone areas access may be restricted as patients are afraid of travelling. During periods of increased violence, the healthcare facilities are looted and healthcare workers intimidated. In violent prone areas, malnutrition is aggravated, harvests are regularly pillaged and access to fields is restricted due to security conditions.
Conclusion
There are various challenges to improving the fragile healthcare systems in Africa. Nurses form the backbone of healthcare service delivery in Africa. The difficulties faced by nurses across the continent are only one challenge; improving dilapidated health facilities and improving on the poor distribution of essential medicines and supplies are other challenges.
In order to improve healthcare systems, nurses needs to be more involved in policy-making, developing healthcare plans and research.

Please note: Africa is not a country and in some of the African countries, the health system is well-established and working. In other’s it’s not going that well. I’m aware that this blog makes blanket statements, however it refers to my experiences and conversations in the country’s that I have travelled to.

References
Munjana OK, Kibuka S, Dovlo D. (2005) The nursing workforce in Sub-Saharan Africa. Issue paper no 7. International Council of Nurses.
Sun C. Larson E. (2015) Clinical nursing and midwifery research in African countries: a scoping review. International Journal of Nursing Studies. 2015 May;52(5):1011-6. doi:10.1016/j.ijnurstu.2015.01.012.
http://www.our-africa.org/women
http://www.who.int/healthsystems/publications/abuja_declaration/en/
Rohde JT. (2015). The relationship between Access to Healthcare and Civil conflict. College of William and Mary. Honors Theses. Paper 99
Abuja Declaration 2001
Klopper HK, Uys LR. 2012. State of Nursing and Nursing Education in Africa: a country by country review. Sigma Theta Tau international
The nursing Education Partnership Initiative in the Democratic Republic of Congo. (2012). Assessment of nursing and midwifery education and training capacity at seven training institutes in the DRC. Synthesis report. Prepared by CapacityPlus, Intrahealth International

In case of emergency….

A few days ago I was meeting a friend that is never late and is basically glued to her phone.  So when she was 30 minutes late, not answering her phone, not reading or replying to messages, I started worrying about her.  I ran through few worse-case scenarios, including an accident etc.

And as I was going through scenario’s I realised that if something happened to her and she was unresponsive I had no way of informing her parents, siblings or other close friends.  I also had no idea whether she is on medical aid, her past medical history, her allergies etc. Somehow we’ve never covered these things in our general conversations. And then I thought that as friends that hike together, go camping and do other outdoors stuff, it’s actually irresponsible and risky not to know these basics about friends.

A quick check with some other friends revealed that most of us have never thought about emergency preparedness as a ‘friend responsibility’.  Since then I’ve been on a mission to get a few basic things sorted and to educate some of my friends of the importance of sharing emergency contact details. I think that it’s especially important for those of us that live far away from our family, we will have to rely on our friends should anything happen.   

So here is a few things that you can do today, it’s by no means exhaustive, but it covers the basics!

  • Ask your friends for their closest family member’s contact details, this includes a physical address.  In case of an injury or sudden severe illness, you want to know that you can get hold of their family.
  • Ask your friends for their basic medical information including known allergies, if they are on chronic medication and maybe even whether they are organ donors, their blood type etc.
  • Confirm if they are on medical aid and know where they keep their medical aid cards and identity documents.  And remember to always take these with when you go camping or hiking.
  • At least one other friend should have access to your house. And maybe  even know where you keep your important documents including a will, information on disability cover etc.
  • Know this: if a phone is locked you can still access emergency services on the phone, press on the screen and dial 112.  I think that this is really important to teach children so that they can obtain help should something happen to a parent.

 

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Press Emergency button

 

Use your phone! Save your emergency details and basic information on your phone, I’m not sure how this works on other phones  but here goes for iPhone: Go to the health app, click on medical ID.  Enter your details; emergency contacts and add medical aid details at medical notes.

Medical-ID-Tab

In order to access the patient’s emergency contact details on a locked phone, simply press on emergency and it will give you the option to select medical ID.  Click on that, viola! Not only do you have the medical details, but you can also call the emergency contacts and access their information such as physical address.

As the boy scouts say: Be Prepared!

This is not my normal type of blog, I just really felt that I had to share it though.  Please share and if you have more tips feel free to comment and add. 

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The end of the short course route to become a SA paramedic

For years there have been rumors about the end of short course training for paramedics in South Africa.  It became real on 27 January 2017 when the Department of Health published a regulation pertaining to the qualifications for registration of the short courses. 

A brief background to those unfamiliar with the system:  Until now there has been a dual system to become a paramedic.  Taking the short course route meant completing a 4-6 week course in order to qualify as a Basic Ambulance Assistant (BAA). The BAA can do the basics including (but not limited to) the administration of oxygen and splinting of fractures.  For a long time (possibly still?) BAA’s was the backbone of the Emergency Medical Services (EMS).  Especially in the urban areas where there is a high density of hospitals, the BAA is valuable because they can perform basic care, load the patient and rapidly proceed to the closest facility.  This implies fast access to definitive care.  Career-wise to advance the BAA had to complete working full-time for 6 months or 1000 hours as prerequisite to apply for the next course. If successful, the BAA could then do the Ambulance Emergency Assistant (AEA) course.  The AEA can perform skills including nebulization and commencing IV therapy.  Again after 1000 hours or 6 months of full-time working, they can apply to do the 9 month advanced life support paramedic course.  This course has limited space and the entry exams are tough; thus AEA’s often have to work for a number of years and gain experience prior to doing the course.  This pathway to become an Advanced Life Support Paramedic is now being scrapped in favor of a 4 year degree program at selected UT’s.

In many ways this agenda has been driven by a desire to professionalize and create the capacity for research within the field.  Still there is an eerie sense of dèjá vu; the impact on training is similar to what happened to nursing not so long ago.  During the late 90’s in an attempt to restructure nursing, various colleges were shut down, shorter nursing courses were suspended, the university curriculums were adapted and the intake of nursing students at these institutions reduced.  Shortly thereafter community service for new nursing graduates became compulsory and to become a nurse meant 5 years of studying.  Fast forward about 20 years, and South Africa has an estimated shortage of 45 000 nurses, with only 3 500 new nurses are trained per year.  According to Nursing Council statistics 48% of Professional Nurses are above the age of 50 with 25% of nurses under the age of 40; of these only 5% are under the age of 30.  The shortage of nurses is dire and will continue for the foreseeable future, especially when the 48% above 50 start retiring in the next decade. 

The shortage gave rise to contract nursing, also known as ‘moonlighting’ where nurses work overtime shifts or only work as agency nurses.  Moonlighting caused (well-described) drastic consequences on the quality of nursing care in South Africa.  Furthermore it attributes nurse burnout.  Sadly it also costs the hospitals more money to buy-in agency staff, it increases the load on the nurse managers to process hours, plan staffing, negotiate and book agency staff. 

There are a few lessons to learn from the above.  Sadly though, paramedicine seems to be on the same trajectory. Other concerns include

1)      University qualified paramedics = higher salary expectations = higher budgetary demand

Remunerating a workforce that consists of degree paramedics will be at a far higher cost than paying different levels of short-course practitioners.  In a country where the health system is struggling with budgetary constraints exists I’m not sure whether the provincial health services would be able to accommodate increased salary budget demands without compensating other vital aspects such as vehicle maintenance, equipment or stocks.

2)      Related to the above.  The cost to train a degree paramedic

The cost per student is higher at a university than with in-service training. The duration of the courses are longer, meaning that any investment will only yield results in 4-5 years.  How can this be seen as cost-effective in a country with budgetary constraints, a growing burden of disease and ever-increasing demand? 

3)      Brain drain

It is not a new problem that newly qualified paramedic graduate leave the country in hordes.  They earn better salaries in Qatar, the UK and as contractors for the oil and gas industry. Thus the back bone of the provincial services has remained short course paramedics.  In the Western Cape the vacancy rate for paramedics in the public sector is 7.5% (2015/16 DOH report).  This is the highest across all healthcare professionals in the public sector; it is even higher than the nursing vacancy.  Taking away the short courses, spending all the money to train graduates and then have them leave the country doesn’t seem to solve the pressing issue of high vacancy rates.  The vacancy rate might already imply a paramedic shortage. 

4)      Loss of tacit knowledge and experienced practitioners 

Over the past decade the career progression for paramedics that came through the ranks by doing the short-courses has become more and more limited. Often despite their years of experience, they cannot apply for management positions; they earn less that their newly qualified inexperienced colleagues.  Because they know the system they often end up carrying newer qualified degree paramedics.  Over the years with the constant threat of the end of short-course training, and the rise of more and more degree paramedics, these practitioners have become disgruntled and unhappy.  Now that their qualification is officially extinct, why should they stick around in the industry? And can South Africa really afford to lose their knowledge and experience?

5)      Increased barriers to access emergency care 

I’ve been part of the Hout Bay Volunteer Ambulance Service (HBVEMS) since 2004, a community-driven ambulance service that predominantly functions with short course practitioners.  With no more short courses, the growth and sustainability of services such as HBVEMS are stunted.  The volunteer pool will shrink until there is no service left.  This is true for volunteer services across the country and it creates a gap in service delivery and access to essential emergency care.

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6)      Impact on fire services 

In Hout Bay and other areas, the fire services fill an important gap as first responders.  Often patients are taken to fire stations where care is rendered whilst waiting for an ambulance.  This is done by fire fighters that have completed the short courses.  As rendering emergency care is not their primary duty is seems nonsensical for them to do a 4 year degree.  Again the impact of fire fighters no longer being qualified to render basic care will be felt by the community.

7)      Paramedicine = exclusivity

A degree program has higher entry requirements than skills based programs, helping the professionalization of the field.  I fail to see how the professionalization and more elite paramedical qualification contributes to better serving the need of our country’s growing population.  Would the same money to train degree paramedics, not be more useful if used to purchase more ambulances?   Is scrapping short-courses really in-line with the needs of the population of South Africa?  Not to mention that there’s been studies questioning whether having higher qualified paramedics on scene actually equals better care, as they are more likely to spend longer time on scene performing advanced interventions that is not always required.  In the end one of a paramedic’s core functions is to stabilize and transport to definitive care. 

The key arguments for discontinuing short courses are that short courses do not comply with the National Qualification Framework Act.  And in order to professionalize paramedicine a degree program is required.  It has also been stated that the Health Professionals Council of South Africa has to protect the public by ensuring the registration of appropriately qualified emergency care providers who has the skills to practice their profession safely. 

“We learn to do something by doing it. There is no other way.” – John Holt

I completely agree that there should be a degree program that helps advance the field, promote research and education.  However in the end, a good paramedic is someone that can apply their skills.  Paramedicine is a skills-based function and whether having a degree equals being more skilled to perform practical interventions are questionable.  I disagree that the ‘professionalization’ of paramedicine at the expense of short-course programs is the best way forward.  Especially in a country that has a growing population, quadruple burden of disease and inequality in accessing care.  In fact to solve some of the problems that we face in emergency care, maybe we should rather follow one of the ideals of the Gates foundation:  “The ideal is creating a skills-based credential that is well trusted and well understood enough that employers view it as a true alternative to a degree” (Bill Gates 2013)

Firefighters, tacit knowledge and rapid decisions

For the past week, Cape Town firefighters have relentlessly been battling fires across the city and it appears that every hour on the news there is another fire to manage.  It’s been said that every fire is different, so have you ever wondered how firefighters decide on the best course of action with so many variables and very little time to exhaust all the possible options and outcomes?

In the late 70’s Gary Klein explored the above question. One of his first discoveries was that the laboratory models of decision-making were not sufficient for the conditions that firefighters work in.  Furthermore during interviews many firefighters were unable to explain how they reached their conclusions and some experienced firefighters stated that they’ve never made any decisions. This led to some fieldwork observing the firefighters and conducting post-incident interviews to explore whether and how firefighters make decisions.  The findings and further work on decision-making resulted in the Recognition Primed Decision-making model (RPD), naturalistic decision-making and recently the shadowbox concept.

Initially Klein hypothesized that firefighters narrow their options to two and then choose the best option of these.  Findings demonstrated that 80-90% of the firefighters used the same RPD strategy to decide:  They would only generate one option based on cues in the environment. Once they’ve selected their option, they would mentally imagine the next step e.g. how the fire are likely to spread, which houses are likely to collapse and then act on that.

Klein discovered that in high-stress, uncertain situations the level of expertise of the decision-maker plays a major role. Decision-making are based on tacit knowledge where the ‘new’ situation contains something familiar or a cue that allows the decision-maker to act on a ‘prototype’ of what worked before.  Experienced firefighters can thus rapidly match current situation to past pattern and literally instantaneously and seemingly intuitively know what to do.

As an example, Klein refers to an interview where firefighters had to enter a house that was on fire.  Within seconds the commander ordered everyone to leave the house, literally as the last firefighter escaped, the floor collapsed.  In retrospect, the commander explained that the fire was too quiet and that was unusual, he also felt that his ears were too hot.  The combination of these impressions prompted the reaction.  At the time he didn’t know what was wrong, but he knew something was amiss.  It turned out that the heart of the fire was not on the first floor where they entered, it was in the basement that they didn’t know about.  If the commander didn’t pick up on the subtle cues, the entire team could’ve been killed.

Because fires grow exponentially, the faster the firefighter can react, the more likely it is that the fire can be contained. It was found that in these situations, the decision-maker opts for the first workable idea and not necessarily the best option (satisficing).  It should be mentioned that experienced decision-makers are very likely to generate a plausible first option. Laboratory decision models that require comprehensive evaluation and multiple options are simply not feasible as the fire would be out of control by the time a decision has been taken.  It’s thus unlikely that reflective deliberation is the key to successful decisions whilst firefighting.

All of the above was described in the Recognition Primed Decision model (RPD).  In the RPD model, a suitable reaction is immediately considered and recognized.  RDP relies on the intuitive pattern finding, where people use their experience to match the situation to patterns that they have learned.  This is followed by conscious analysis in the form of visualizing or mental simulation to ‘test’ the option. Both intuitive pattern finding and conscious analysis are required. According to the RPD model it becomes a cycle where the decision-maker creates a mental picture of what a reasonable solution looks like, the actions required to reach the ideal outcome and then mentally evaluates the effects of the action.

 

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RPD model

 

These findings have been replicated in other environments including military command and control, management of offshore oil installations and neonatal critical care nurses.  These environments are all dynamic, constantly shifting, outcomes are uncertain and decisions are time-critical.

I think that the RDP model enforces the importance of tacit knowledge in high stress environments.  This is knowledge that is deeply rooted, often people are not aware of the extent of their knowledge e.g. firefighters saying that they don’t make decisions. Tacit knowledge is the know-how that is not contained in the procedure manuals or policies.  It is what allows people to perform tasks and provide local knowledge without focused attention.  There is only one way to obtain tacit knowledge and that is through experience, and preferably this experience should be guided by an experienced mentor.  Sadly tacit knowledge is lost when experienced people leave an organization or industry.

Emergency care is an industry in which tacit knowledge is really important. Even just driving an ambulance into some neighborhoods requires tacit and local knowledge.  Rapid and effective decisions are required prehospital, during major incidents and in overcrowded emergency centers. In these situations the decision-making density is high; decisions are made amidst constant, dynamic change.  The information available to the decision-maker is incomplete, ambiguous or not available. Decisions are often required within seconds rather than minutes.

The RPD has two preconditions namely

1)      There needs to be adequate cues in the environment to assist the decision maker

2)       The opportunity in an environment to learn from the cues as it takes time to reach the point of expertise to make these decisions

These preconditions can be used as pointers on how to improve decision-making in emergency care situations.  The first is building a repertoire of patterns that will assist decision-making.  A great method that is used clinically is simulation training; this could and should be extended to operational decisions during crises situations. In the prehospital environment this is already well-established during training.

The other precondition is the one that I think emergency care and greater healthcare industry often disregards: tacit knowledge.  It takes time to build adequate experience which allows good decisions.  Consider the vast amount of nurses, paramedics and firefighters that has left the industry in the past ten years, I daresay that the industry disregards the expertise that comes with 20 – 30 years of hands-on experience in the field.  These experts are not only leaving because of better salaries, but it’s for better work conditions, opportunities, career progression and to feel acknowledged. Tacit knowledge should be aggressively guarded by the industry!

Novices see only what is there; experts can see what is not there – Klein

Read more by searching for any work by Gary Klein including his work on macro cognition; sources of power, gaining insights, naturalistic decision-making and sense-making

https://www.researchgate.net/profile/Gary_Klein6/publication/235418838_A_Recognition_Primed_Decision_RPD_Model_of_Rapid_Decision_Making/links/565512fd08aefe619b1a44f0.pdf

 

The garbage people: unintended consequences of change

With a capacity for 20 000 people, the cave church of St. Simon are said to be the largest Christian church in the Middle East.  The church’s limestone walls have breath-taking carvings.  Getting there requires travelling through a section of Cairo’s Manshiyat Naser neighborhood known as the garbage city. This is breath-taking in a completely different way…

Your senses alert you that this is the garbage city, the putrid smell is intense and there is garbage everywhere.  Garbage fills the narrow streets, the balconies, kids play in it and the shops are hidden between garbage. Garbage city is home to the Zabaleen (garbage people).  The Zabaleen travels from house-to-house in Cairo, collecting household waste and transporting the collected waste back to the garbage city. Each family specialize in a type of garbage that they sort, recycle and sell.

Until 2003 the Zabaleen collected garbage at almost no cost to the government and residents of Cairo.  Their main income came from recycling the garbage.  It’s estimated that in 2003 the Zabaleen recycled 80% of the garbage collected.  This was described as one of the most efficient recycling systems globally and it has earned the Zabaleen international acknowledgement.

 

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View from the car window

 

The Zabaleen are Christians in a Muslim majority country.  In the recycling business this provides them with a competitive advantage: the ability to keep pigs.  The Muslim’s religion does not permit living close to or keeping pigs. Most of the waste collected is food waste; the Zabaleen recycles this by feeding it to their pigs to fattening them up.  Once fat, the pigs are sold, providing further income.

The improvement: fake green grass on the other side of the fence

In 2003, the Mubarak government decided to ‘modernize’ the garbage collection system of Cairo by adopting the systems used in Europe.

Unintended consequences of the change

  • Adverse impact on the socio-economic stability of the Zabaleen
  • The modern mechanism of compressing garbage complicated recycling and the level of recycling dropped
  • Cairo’s streets were too narrow for the mechanized equipment, uncollected garbage was dumped by the residents
  • The new collection system introduced higher fees resulting in further illegal dumping, burning of waste and increased pollution

To compare: in 1997 the Zabaleen collected 3000- 4000 tons of garbage per day at almost no cost to the government; they recycled about 80% of the waste collected.  In 2004 the government was paying ten times more to have only 60% of the garbage collected and 20% of the collected garbage was recycled.

 

Then in 2009, the Egyptian government ordered the slaughter of some 300 000 pigs as precautionary measure to prevent swine flu (H1N1). This effectively destroyed another vital aspect of the Zabaleen’s recycling methods.  The WHO called the killing ‘scientifically unjustified’. The government’s actions against the Zabaleen was almost certainly politically motivated and grounded in religious tensions.

Moral of the story

There is a tendency to view another country, organization or functional work unit’s methods as superior.  It is problematic when these methods are adopted without considering feasibility, cultural differences and why the current system operates the way it does. There is always a reason for the faults in the current system, a few examples would include hierarchies, history or power struggles.

 

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The grass is not always greener on the other side….

 

Even in healthcare, when low-middle income countries (LMIC) undertake to improve their healthcare systems, they often model their interventions after high income countries (HIC).  However, HIC have the enabling infrastructure to support advanced health systems. In LMIC’s with poor roads, it would be more sustainable to invest in bicycle ambulances than to establish ambulance services.  Rather than develop university curriculums, train community first responders in the rural areas.  Instead of creating an urban center of excellence, provide electricity and running tap water in all the small rural clinics.

To the Egyptians, investing in the Zabaleen’s existing informal system would’ve probably been more beneficial, cost effective and sustainable.  By disregarding the functioning informal system, the policy makers destroyed a functioning system and adopted a system not suitable for their setting.  This resulted in failure so devastating that it’s even been cited as a reason for the 2011 uprising.

There are a few lessons that we can take from this:

  • Don’t discard local ownership
  • Thoroughly observe and analyze the current situation prior to suggesting change
  • The above implies spending time to explore the current situation
  • The first consideration should always be to augment the local/informal system or to formalize the informal system
  • If the solution is adopted, make it context specific, in other words innovate on what worked somewhere else
  • When formal systems are developed it should be done considering the integration of formal and informal systems from the beginning

Disregarding the above will result in change programs that are not sustainable.  Not integrating formal and informal systems result in parallel systems where the systems compete to the detriment of both.

Conclusion

A year after implementing the ‘modern’ system the Egyptian policy makers had to acknowledge failure. A decade later they are taking steps to integrate the Zabaleen into the formal system.  They are also investing in the Zabaleen that now have uniforms and vehicles.

In short, don’t solve problems that don’t require solving, observe, investigate and find the real and right problems.  Solutions should be feasible, involve the locals and the informal systems and don’t ever blindly adopt, rather innovate and make change context-specific.

To watch a short documentary about the garbage people

https://www.youtube.com/watch?v=D0s7WsoC528

Read more

Wael Salah Fahmi. Keith Sutton.  (2006)  Cairo’s Zabaleen garbage recyclers: multi-nationals take over and state relocation plans.  Habitat International 30 (2006) 809-837

http://www.yourmiddleeast.com/culture/turning-waste-into-wealth-with-cairos-garbage-people-photos_31874

https://www.theguardian.com/global-development/poverty-matters/2014/mar/27/waste-egypt-refuse-collectors-zabaleen-cairo

http://weekly.ahram.org.eg/News/14892/32/Egypt%E2%80%99s%20garbage%20problem.aspx

https://en.wikipedia.org/wiki/Zabbaleen

http://www.samaanchurch.com/en/about_us.php

http://news.nationalgeographic.com/news/2009/04/090430-egypt-swine-flu-video-ap.html

 

Emergency care in Africa: There is no free lunch…

Let hunger be ranked first because if you are hungry you cannot work! No, health is number one, because if you are ill you cannot work! – Discussion group ranking; Musanya Village, Zambia1

The basic economic premise states that our wants are unlimited but our resources to obtain our wants are limited. On an individual level this implies that we are constantly prioritising desires in order to afford the most important ones (I’m using the word desire as an umbrella term for needs and wants). Sometimes we prioritize in a conscious way through budgeting, negotiating with our partners, saving for large expenditures or investing. At other times it’s automatic and we are largely unaware of the process. These ‘automatic’ decisions are based on beliefs and values, rooted in our culture, community and environment.

Every so often the desires are mutually exclusive and choosing one option means giving up on another, thus we make trade-offs or sacrifices. Our willingness to make a trade-off depends on the perceived benefit of the chosen option. The trade-off is not always financial, convenience or time might be valued more than cost. If the benefit is unknown or uncertain, the trade-off is viewed as risky and not worth the effort or cost.

Economics 101

  • Humans have unlimited needs and limited resources
  • We can’t have everything that we need or want
  • What you are willing to give up depends on what you get out of it (the benefit)
  • The decision is not always easy

fsdfs

The relation between income, benefit and trade-off can be seen in the triangle. Income represents the ability to raise financial resources to pay for care and it includes savings, obtaining a loan, etc. Benefit refers to treatment outcome and adequacy of emergency care. The trade-off is the sacrifice made to afford the benefit.

For people living in Africa the benefit is murky and the cost high. Ambulance services are rudimentary limiting the ability to obtain care at the site of injury, transport to definitive care or care during transit. Upon arrival at the health facility, Africans are burdened with out-of-pocket payments prior to stabilisation, resuscitation or basic care. In addition, due to low government investment, healthcare facilities create alternative funding methods to afford supplies, staff etc. These methods generally involve requesting (demanding) supplementary payments, known as informal payments, bribes or gifts. Paying these allows the patient to skip the queue, get a bed and receive care. Other cost considerations are the ‘hidden’ or indirect costs including the travelling costs, transportation, carer accommodation, waiting time and lost income opportunities.

Sadly, these expenditures are incurred to obtain care in facilities where infrastructure is lacking. Running tap water, electricity, basic equipment or medication are not a given. Also healthcare providers are often not well-equipped with basic emergency care skills.

Trade-offs are made in order to afford the care and may include

  • Reducing the household’s food consumption and budget
  • Selling a girl child into underage marriage
  • Selling assets such as livestock or dwelling
  • Removing children from school
  • Child labour
  • Selling foodstuffs like maize
  • Taking out loans at a high interest rates
  • If there’s more than one patient, prioritising care for one member at the expense of another

Basically, accessing emergency care requires massive trade-offs for a very uncertain benefit. An alternative is to not access care and hope for the best. This becomes a reasonable option when one considers that each year approximately 25 million Africans are pushed into poverty due to healthcare expenditure. Catastrophic health expenditure is calculated in various ways; however most methods exclude informal, indirect costs and the depletive sacrifices. The entire household suffers the repercussions of financial ruin.

tradeoff-for-blog

Emergency care benefits only the patient. The household makes the sacrifice so that one person can potentially benefit. It’s further complicated due to the urgency, emergency care requires time-critical interventions and delaying care can be devastating. The decisions taken shortly after a traumatic incident are probably not well-thought through, rational or informed. Predicting the required sacrifices is confounded due to different types of cost, changing costing structures and a whole lot of unknowns. It’s a tough call.

When we are involved in developing and strengthening systems in other communities than our own, we need to be aware that as outsiders we don’t understand the daily reality of those we serve. We can’t assume the local needs, wants, trade-offs and norms. Our observations are clouded by our own bias. This can be overcome by establishing ways to enable community participation that allows the implementation of sustainable and locally owned interventions.

On another level, advocacy for the greater good of accessible care includes continued lobbying for universal access to healthcare. Emergency care, especially out-of-hospital systems can significantly reduce cost as a barrier to access care.

                        For me a good life is to be healthy1 – Old Man Ethiopia

This blog includes some aspects that I addressed at the BADem symposium regarding the trade-offs that people make in Africa to access healthcare.

  1. Dying for change, poor people’s experience of health and ill-health. World Bank Study 2000. www.worldbank.org/poverty/voices

 

 

 

BADEM2016

Yesterday I had the privilege to participate in the emergency medicine symposium held by BadEM in Cape Town.  Conferences, symposiums and workshops that attract big name-speakers are often expensive and definitely unaffordable to students.  This symposium not only attracted THE big names in Emergency Medicine in South Africa, it was also FREE allowing everyone to participate and it filled 400 seats.  

The BadEm team are great believers in the power of social media, especially free open access medical education (FOAMed) and the power of social media was once again demonstrated.  By mid-morning (if not earlier) #BADEM16 was trending on twitter.  Word about what is important in emergency care in Africa gained a global audience and tweets were flowing in from all over the world.  How brilliant!

The BADEM16 talks was thought –provoking and covered themes including to stop using first world solutions for the developing world; should we be training CPR in low resource settings; owning up and learning from mistakes, errors and omissions; how to have the difficult death conversation with the family and how to allow the patient to die with dignity.  And that we need new solutions for the same old problems. 

I found it refreshing that clinical expertise took a bit of backseat, allowing the conversation to be on things that I think really matters, such as how do we develop sustainable cost-effective systems that the patients can trust and where people actually want to and can effectively work in the system.

Emergency Medicine is leading the way to new frontiers.  By creating global awareness, the need for emergency care systems can become a priority, resulting in better resource allocation and investment into emergency care systems.

In conclusion, this is without doubt an exciting time in the development of emergency care in Africa.  I feel incredibly blessed to be part of the story that we are writing, the story of how emergency care in Africa was developed.  To the BADEM team, well done!

See some pics below

NS – a blog to follow shortly on my talk and the fact that there is no free lunch

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check out badem.co.za

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Prof Wallis talking about CPR

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Some of the speakers and the BADEM team

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One of the tweets during my talk